Inspection visit
Inspection
Citations
15 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
- 0020GeneralS&S Fpotential for harm
Establish policies and procedures including evacuation.
- 0031GeneralS&S Fpotential for harm
Provide emergency officials' contact information.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- 0035GeneralS&S Fpotential for harm
Provide family notifications of emergency plan.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0311GeneralS&S Fpotential for harm
Have an enclosure around a vertical opening shaft.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0521GeneralS&S Epotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
FAQ · About this visit
Common questions about this visit
What happened during the October 2, 2024 survey of Willowdale Health Services?
This was a inspection survey of Willowdale Health Services on October 2, 2024. The surveyor cited 15 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Willowdale Health Services on October 2, 2024?
Yes, 15 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, an..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.